Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-29T01:39:09.920Z Has data issue: false hasContentIssue false
  • English
  • Français

Application of the “Plan-Do-Study-Act” Model to Improve Survival after Cardiac Arrest in Korea: A Case Study

Published online by Cambridge University Press:  06 December 2019

Joo Yeong Kim ,
Hanjin Cho Open the ORCID record for Hanjin Cho [Opens in a new window] ,
Jong-Hak Park ,
Joo-Hyun Song ,
Sungwoo Moon ,
Hongjae Lee ,
Hyun Ju Yang ,
Juliana Tolles Open the ORCID record for Juliana Tolles [Opens in a new window] ,
Nichole Bosson Open the ORCID record for Nichole Bosson [Opens in a new window]  and
Roger J. Lewis
Joo Yeong Kim
Affiliation:
Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, South Korea
Hanjin Cho*
Affiliation:
Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, South Korea
Jong-Hak Park
Affiliation:
Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, South Korea
Joo-Hyun Song
Affiliation:
Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, South Korea
Sungwoo Moon
Affiliation:
Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, South Korea
Hongjae Lee
Affiliation:
Ansan Public Health Center, Ansan, South Korea
Hyun Ju Yang
Affiliation:
Ansan Fire Department, Ansan, South Korea
Juliana Tolles
Affiliation:
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Nichole Bosson
Affiliation:
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA David Geffen School of Medicine at UCLA, Los Angeles, California, USA Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California, USA
Roger J. Lewis
Affiliation:
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA David Geffen School of Medicine at UCLA, Los Angeles, California, USA Berry Consultants, LLC, Austin, Texas, USA
*
Correspondence: Hanjin Cho, MD, PhD Department of Emergency Medicine Korea University College of Medicine Korea University Ansan Hospital 516 Gojan-dong, Danwon-gu, Ansan-si, Gyunggi-do, 425-707, Korea E-mails: [email protected]; [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

Low rates of bystander cardiopulmonary resuscitation (CPR) were identified as a shortcoming in the “chain of survival” for out-of-hospital cardiac arrest (OHCA) care in the Korean city of Ansan. This study sought to evaluate the effect of an initiative to increase bystander CPR and quality of out-of-hospital resuscitation on outcome from OHCA. The post-intervention data were used to determine the next quality improvement (QI) target as part of the “Plan-Do-Study-Act” (PDSA) model for QI.

Hypothesis:

The study hypothesis was that bystander CPR, return of spontaneous circulation (ROSC), and survival to discharge after OHCA would increase in the post-intervention period.

Methods:

This was a retrospective pre/post study. The data from the pre-intervention period were abstracted from 2008–2011 and the post-intervention period from 2012–2013. The effect of the intervention on the odds of ROSC and survival to hospital discharge was determined using a generalized estimating equation to account for confounders and the effect of clustering within medical centers. The analysis was then used to identify other factors associated with outcomes to determine the next targets for intervention in the chain of survival for cardiac arrest in this community.

Results:

Rates of documented bystander CPR increased from 13% in the pre-intervention period to 37% in the post-intervention period. The overall rate of ROSC decreased from 18.4% to 14.3% (risk difference −4.1%; 95% CI, −7.1%–1.0%), whereas survival to hospital discharge increased from 3.9% to 5.0% (risk difference 1.1%; 95% CI, −1.8%–3.8%), and survival with good neurologic outcome increased from 0.8% to 1.6% (risk difference 0.8%; 95% CI, −0.8%–2.4%). In multivariable analyses, there was no association between the intervention and the rate of ROSC or survival to hospital discharge. The designated level of the treating hospital was a significant predictor of both survival and ROSC.

Conclusion:

In this case study, there were no observed improvements in outcomes from OHCA after the targeted intervention to improve out-of-hospital CPR. However, utilizing the PDSA model for QI, the designated level of the treating hospital was found to be a significant predictor of survival in the post-period, identifying the next target for intervention.

Keywords

bystander CPRcardiopulmonary resuscitationEMSout-of-hospital cardiac arrest
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 35 , Issue 1 , February 2020 , pp. 46 - 54
Copyright
© World Association for Disaster and Emergency Medicine 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ro, YS, Shin, SD, Song, KJ, et al.A trend in epidemiology and outcomes of out-of-hospital cardiac arrest by urbanization level: a nationwide observational study from 2006 to 2010 in South Korea. Resuscitation. 2013;84(5):547–557.CrossRefGoogle ScholarPubMed
McNally, B, Robb, R, Mehta, M, et al.Centers for Disease Control and Prevention. Out-of-hospital cardiac arrest surveillance – Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005-December 31, 2010. MMWR Surveill Summ. 2011;60(8):1–19.Google Scholar
Zive, D, Koprowicz, K, Schmidt, T, et al.Resuscitation Outcomes Consortium I. Variation in out-of-hospital cardiac arrest resuscitation and transport practices in the Resuscitation Outcomes Consortium: ROC Epistry-Cardiac Arrest. Resuscitation. 2011;82(3):277–284.CrossRefGoogle Scholar
Kleinman, ME, Brennan, EE, Goldberger, ZD, et al.Part 5: adult Basic Life Support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S414–S435.CrossRefGoogle ScholarPubMed
Institute for Healthcare Improvement. Model for Improvement. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx. Accessed January 17, 2019.Google Scholar
Cho, H, Moon, S, Han, G, Park, J-H, Choi, J, Hwang, S.Out-of-hospital cardiac arrest: incidence, process of care, and outcomes in an urban city, Korea. Clin Exp Emerg Med. 2014;1(2):94–100.CrossRefGoogle Scholar
Rivera, NT, Kumar, SL, Bhandari, RK, Kumar, SD.Disparities in survival with bystander CPR following cardiopulmonary arrest based on neighborhood characteristics. Emerg Med Int. 2016;2016:6983750.CrossRefGoogle ScholarPubMed
Gräsner, J-T, Lefering, R, Koster, RW, et al.EuReCa ONE Collaborators. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one-month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation. 2016;105:188–195.CrossRefGoogle Scholar
Kitamura, T, Kiyohara, K, Sakai, T, et al.Epidemiology and outcome of adult out-of-hospital cardiac arrest of non-cardiac origin in Osaka: a population-based study. BMJ Open. 2014;4(12):e006462.CrossRefGoogle ScholarPubMed
Wang, C-Y, Wang, J-Y, Teng, N-C, et al.The secular trends in the incidence rate and outcomes of out-of-hospital cardiac arrest in Taiwan--a nationwide population-based study. PloS One. 2015;10(4):e0122675.CrossRefGoogle ScholarPubMed
Henry, K, Murphy, A, Willis, D, et al.Out-of-hospital cardiac arrest in Cork, Ireland. Emerg Med J. 2013;30(6):496–500.CrossRefGoogle ScholarPubMed
Jacobs, I, Nadkarni, V, Bahr, J, et al.Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004;110(21):3385–3397.CrossRefGoogle Scholar
Nakahara, S, Tomio, J, Ichikawa, M, et al.Association of bystander interventions with neurologically intact survival among patients with bystander-witnessed out-of-hospital cardiac arrest in Japan. JAMA. 2015;314(3):247–254.CrossRefGoogle Scholar
Malta Hansen, C, Kragholm, K, Pearson, DA, et al.Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010–2013. JAMA. 2015;314(3):255–264.CrossRefGoogle ScholarPubMed
Song, KJ, Shin, SD, Park, CB, et al.Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: a before-after population-based study. Resuscitation. 2014;85(1):34–41.CrossRefGoogle Scholar
Engdahl, J, Abrahamsson, P, Bång, A, Lindqvist, J, Karlsson, T, Herlitz, J.Is hospital care of major importance for outcome after out-of-hospital cardiac arrest? Experience acquired from patients with out-of-hospital cardiac arrest resuscitated by the same Emergency Medical Service and admitted to one of two hospitals over a 16-year period in the municipality of Göteborg. Resuscitation. 2000;43(3):201–211.CrossRefGoogle Scholar
Carr, BG, Kahn, JM, Merchant, RM, Kramer, AA, Neumar, RW.Inter-hospital variability in post-cardiac arrest mortality. Resuscitation. 2009;80(1):30–34.CrossRefGoogle ScholarPubMed
Stub, D, Schmicker, RH, Anderson, ML, et al.Association between hospital post-resuscitative performance and clinical outcomes after out-of-hospital cardiac arrest. Resuscitation. 2015;92:45–52.CrossRefGoogle ScholarPubMed
Spaite, DW, Bobrow, BJ, Stolz, U, et al.Arizona Cardiac Receiving Center Consortium. Statewide regionalization of post-arrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome. Ann Emerg Med. 2014;64(5):496–506.e1CrossRefGoogle Scholar
Iqbal, MB, Al-Hussaini, A, Rosser, G, et al.Predictors of survival and favorable functional outcomes after an out-of-hospital cardiac arrest in patients systematically brought to a dedicated heart attack center (from the Harefield Cardiac Arrest Study). Am J Cardiol. 2015;115(6):730–737.CrossRefGoogle Scholar
Sunde, K, Pytte, M, Jacobsen, D, et al.Implementation of a standardized treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007;73(1):29–39.CrossRefGoogle Scholar
Dumas, F, Cariou, A, Manzo-Silberman, S, et al.Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv. 2010;3(3):200–207.CrossRefGoogle ScholarPubMed
Kim, TH, Lee, EJ, Shin, SD, et al.Neurological favorable outcomes associated with EMS compliance and on-scene resuscitation time protocol. Prehosp Emerg Care. 2018;22(2):214–221.CrossRefGoogle ScholarPubMed
Perkins, GD, Ji, C, Deakin, CD, et al.PARAMEDIC2 Collaborators. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379(8):711–721.CrossRefGoogle ScholarPubMed
Kudenchuk, PJ, Brown, SP, Daya, M, et al.Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest. N Engl J Med. 2016;374(18):1711–1722.CrossRefGoogle ScholarPubMed
Shin, SD, Kitamura, T, Hwang, SS, et al.Seoul–Osaka Resuscitation Study (SORS) Group. Association between resuscitation time interval at the scene and neurological outcome after out-of-hospital cardiac arrest in two Asian cities. Resuscitation. 2014;85(2):203–210.CrossRefGoogle ScholarPubMed